1. 1

    Do not test for inherited thrombophilia for placental mediated complications 

  2. 2

    Do not do repeat testing for proteinuria in established pre-eclampsia

  3. 3

    Do not undertake methylenetetrahydrofolate reductase (MTHFR) polymorphism testing as part of a routine evaluation for thrombophilia in pregnancy   

  4. 4

    Do not measure erythrocyte sedimentation rate (ESR) in pregnancy   

As evidence and clinical practice advances, Evolve recommendations will reflect these changes following a review. The latest SOMANZ recommendation developments are outlined below.

Removal of recommendation (2019)

The previous iteration of the SOMANZ ‘Top-Five’ recommendations included:

Do not perform a D-Dimer test for the exclusion of venous thromboembolism during any trimester of pregnancy.

Recent studies have shown that using a D-Dimer in combination with a clinical algorithm can increase the reliability of D-Dimer testing in ruling out DVT and PE in pregnancy.

Furthermore, the alternative to D-Dimer tests for these purposes is the use of imaging tests, which have their own set of risks from radiation exposure. Where previous evidence which suggested D-Dimer testing was highly unreliable would have tipped the scales towards discouraging D-Dimer testing, the new evidence suggests the results of D-Dimer testing can be made more reliable. Thus, it is no longer apparent there would be strong benefits from discouraging the use of D-Dimer testing in these settings if the alternative is imaging.  

At a 7 August 2019 meeting of the SOMANZ Council it was agreed this recommendation be removed. The RACP Evolve team and the NPS MedicineWise Choosing Wisely Australia Clinical Lead also undertook a review.

Due to this change in evidence, and physician support, this recommendation was officially removed in August 2019.

Supporting evidence for the removal of this recommendation

  • Langlois E, Cusson-Dufour C, Moumneh T, et al. Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study. J Thromb Haemost. 2019;17(8):1329-1334
  • van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med 2019; 380:1139-1149.  *

Original Recommendation: Do not perform a D-Dimer test for the exclusion of venous thromboembolism during any trimester of pregnancy

As D-Dimer levels are raised during pregnancy, they do not have a high positive predictive value for venous thromboembolism (VTE) in pregnancy (i.e. they are unreliable for ruling in VTE in pregnancy). However, nor are they a reliable rule-out test for VTE. One study estimated the sensitivity of the D-Dimer test at 73 per cent, meaning that 27 per cent of patients with a negative D-Dimer had VTE. There have also been case reports of pregnant women with pulmonary embolism presenting with a negative D-Dimer. Therefore, there is no value in performing a D-Dimer test for the exclusion of venous thromboembolism at any trimester in pregnancy.

Supporting evidence

  • Damodaram M, Kaladindi M, Luckit J, et al. D-dimers as a screening test for venous thromboembolism in pregnancy: is it of any use? Journal of Obstetrics and Gynaecology 2009; 29(2):101-32. 
  • McLintock C, Brighton T, Chunilal S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol 2012; 52(1):14-22.
  • To MS, Hunt BJ, Nelson-Piercy C. A negative D-Dimer does not exclude venous thromboembolism in pregnancy. Journal of Obstetrics and Gynaecology 2008; 28(2):222-40.